Week 11: Chp 43: Hyperthyroidism

Question 1

Hyperthyroidism is most commonly diagnosed in who?

Answer 1

can be present at any age but mostly in women between the ages of 20 and 40 years

Question 2

What disease is the most common cause of hyperthyroidism?

Answer 2

Grave’s Disease
-an autoimmune disorder involving antibodies (thyroid-stimulating immunoglobulins) that bind to the thyroid gland, resulting in the enlargement of the thyroid gland and subsequent hypersecretion of thyroid hormone

Question 3

Grave’s Disease

Answer 3

an autoimmune disorder involving antibodies (thyroid-stimulating immunoglobulins) that bind to the thyroid gland, resulting in the enlargement of the thyroid gland and subsequent hypersecretion of thyroid hormone
-most common cause of hyperthryoidism

Question 4

What is hyperthyroidism?

Answer 4

accelerated metabolism

-affects most body systems

Question 5

Primary Vs Secondary Vs Tertiary Hyperthyroidism

Answer 5

• Primary: secondary to excess triiodothyronine (T3) or Thyroxine (T4) from the thyroid gland
• Secondary: with increased secretion of thyroid -stimulating hormone (TSH) from the anterior posterior gland
• Tertiary: as a result of excessive secretion of thyroid-releasing hormone or thyrotropin-releasing hormone (TRH) from the hypothalamus

Question 6

Clinical Manifestations from the increased metabolic rate

Answer 6

-elevated heart rate, cardiac dysrhythmias, and increased heart sounds
-thyroid bruit linked to increased blood flow
-heat intolerance
-increased gastric activity resulting in increased bowel movements
-increased appetite
-weight loss
-fatigue
-nervousness
-insomnia
-light to absent menses
-hair loss
>can also cause exophthalmos (protrusion of the eyeball) and goiter

Question 7

Exophthalmos

Answer 7

protrusion of the eyeball

-a characteristic of hyperthyroidism and results in visual changes

Question 8

Goiter

Answer 8

associated with both hypo and hyperthyroidism and is often the result of hyperplasia (enlargement of organ tissue) of the gland in response to the action of the TSH on thyroid tissue

Question 9

How to Diagnose Hyperthyroidism

Answer 9

Laboratory findings include: elevated serum T3, elevated serum T4, and decreased TSH in primary disorders

• antibodies to TSH are also evaluated, and high titers are correlated with Grave’s disease
• in patients with goiter, thyroid scans may be performed to assess the size, position, and function of the gland
• the uptake of radioactive iodine (RAIU) is measured after oral administration, and normal uptake varies according to the time of measurement; elevations in RAIU are consistent with a diagnosis of hyperthyroidism

Question 10

Treatment Goal

Answer 10

control of the hypermetabolic state is priority

• the management of clinical manifestations, particularly in relation to cardiac function and body temperature is priority
• nonsurgical treatment focuses on ensuring adequate fluid intake because sensible losses are greater secondary to the hypermetabolic state, monitoring for cardiovascular complications, and promoting a quiet, non-stressful environment
• pharmacologic agents may include beta-adrenergic blocking agents because these agents slow heart rate and decrease palpitations

Question 11

Why do patients with hyperthyroidism require close monitoring on their fluid and electrolyte status?

Answer 11

because the hypermetabolic state increases insensible water loss through perspiration as well as elevated metabolic rate

Question 12

long-term management medications for hyperthyroidism

Answer 12

anti-thyroid medications are used including propylthiouracil (PTU), methimazole (Tapazole), and lithium carbonate (Lithonate)
-these medications reduce clinical manifestations of hyperthyroidism by interfering either with the formation or release of thyroid hormone

Question 13

Short-term management medications for hyperthyroidism

Answer 13

iodine preparations may be administered, particularly to patients before thyroidectomy, to decrease blood flow through the thyroid gland in order to decreased thyroid hormone release

Question 14

What is a medical emergency requiring definitive treatment to prevent respiratory compromise and cardiac collapse?

Answer 14

thyrotoxicosis

Question 15

Surgical Management

Answer 15

may be indicated for patients with hypersecreting tumors that are unresponsive to the medications or in patients experiencing tracheal compression due to goiter

Question 16

Because most people demonstrate clinical manifestations of hyperthyroidism while being prepared for surgery, it is priority to establish what?

Answer 16

euthyroid or “normal” function before surgery
-most often accomplished with iodine preparations to decrease vascularity of the thyroid gland in addition to other prescribed anti-thyroid medications, and medications to decrease blood pressure and heart rate as needed

Question 17

Total Thyroidectomy

Answer 17

the patient needs to take thyroid replacement hormone for the remainder of his/her life
-possible complications include removal of all parathyroid tissue, resulting in hypoparathyroidism or damage to the laryngeal nerve that affects swallowing and voice

Question 18

Post-operative priorities after thyroidectomy

Answer 18

monitoring for airway compromise, hemorrhage, hypocalcemia secondary to removal of all parathyroid gland tissue, and damage to the laryngeal nerve

• because hemorrhage is most likely in the first 24 hours, it is important to observe for bleeding around the dressing as well as down the back of the neck
• sandbags may be used to help keep the head in proper alignment, and take care when repositioning to prevent tension on suture line
• positioned in a semi-fowlers position to ease the work of breathing and to decrease the risk of aspiration of oral secretions associated with lying flat on the back
• humidified air is administered to help decrease the viscosity of secretions, and oral suctioning equipment is maintained at beside
• a tracheostomy tray is maintained at bedside because of risk of respiratory compromise secondary to postoperative swelling, tetany (intermittent muscle spasms), and laryngeal damage; tetany develops secondary to hypocalcemia as a result of damage or removal of parathyroid glands during surgery and results in laryngospasm, making oral intubation difficult or impossible; suctioning equipment and supplemental oxygen rare also maintained at the bedside for at least the first 48 hours after surgery
• assessing for damage to the laryngeal nerve is priority; changes in voice quality, particularly hoarseness or a husky tone, may be indicative of laryngeal nerve damage; assessments done every 1 to 2 hours in immediate postoperative period to monitor for changes

Question 19

Complications

Answer 19

• Thyroid storm

- Thyrotoxicosis

Question 20

Thyroid storm or thryotoxicosis

Answer 20

complication of poorly managed hyperthyroidism

• clinical manifestations: tachycardia, fever, systolic hypertension, abdominal pain, tremors, changes in level of consciousness
• airway management and fluid resuscitation are priorities
• anti-thyroid medications may be administered along with iodine preparations
• for management of tachycardia, beta-adrenergic blockers may be administered
• glucocorticoids may also be administered because in high doses these medications decrease the conversion of T4 to the more active T3, as well as decreasing the release of TSH from the anterior pituitary gland
• cooling blankets may be used to treat the hyperthermia
• During crisis, monitor closely for respiratory complications, cardiac dysrythmias, and seizures

Question 21

The clinical manifestations are linked to?

Answer 21

actions of the excessive thyroid hormones and the associated increase in basal metabolic rate

• weight loss because basal metabolic rate can increase by 60 to 100%, leading to accelerated use of glucose, fats, and proteins
• increased gastric motility
• hypoglycemia
• increased systolic BP; tachycardia that may exacerbate cardiac dysrhythmias
• visual changes
• corneal abrasions (secondary to exopthalmos)

Question 22

Nursing Diagnoses

Answer 22

• high risk for decreased cardiac output r/t tachycardia and dysrythmias
• altered nutrition less than body requirements r/t increased metabolic rate secondary to elevated thyroid hormone levels
• hyperthermia r/t accelerated metabolic rate secondary to increased circulating thyroid hormone

Question 23

Nursing Assessments

Answer 23

• vital signs
• intake and output
• eyes and vision
• thyroid hormone levels
• Goiter
• seizures
• daily weight

Question 24

Assessments: Vital signs

Answer 24

hyper-metabolism results in acceleration of the respiratory and cardiovascular system, leading to elevated heart rate and increased respiratory rate
-an elevation in temperature is associated with the hyper-metabolic state

Question 25

Assessment: Intake and Output

Answer 25

increases in insensible fluid loss develop secondary to the hypermetabolic state, leading to increased respiratory rate, increased diaphoresis, and diarrhea

Question 26

Assessment: eyes and vision

Answer 26

exopthalmos leads to changes in shape and structure of the eye that lead to eyeball protrusion and visual changes

Question 27

Assessment: thyroid hormone levels

Answer 27

increased T3 and T4 levels with decreased TSH are characteristics of primary hyperthyroidism

Question 28

Assessment: Goiter

Answer 28

common in Grace’s disease and associated with hyperplasia of thyroid tissue

Question 29

Assessment: Seizures

Answer 29

increased risk for seizure activity linked to hyponatremia and elevated temperature associated with hyper-metabolism

Question 30

Assessment: Daily weight

Answer 30

weight loss occurs despite increased appetite, secondary to the hypermetabolic state
-use of protein stores leads to loss of muscle mass that contributes to weight loss

Question 31

Nursing Actions

Answer 31

• administer anti-thyroid medications as ordered
• administer iodine preparations
• administer beta-adrenergic blocking agents as ordered
• implement cooling measures with elevated temperature
• administer eye lubricant

Question 32

Actions: Administer anti-thyroid medications as ordered

Answer 32

decreases thyroid hormone levels by preventing synthesis of hormone in the thyroid gland or by preventing the conversion of T4 to T3

Question 33

Actions: Administer Iodine Preparations

Answer 33

decreases vascularity of thyroid tissue resulting in decreased thyroid hormone synthesis and release

Question 34

Actions: administer beta-adrenergic blocking agents as ordered

Answer 34

used as supportive therapy to treat the associated clinical manifestations of hyper-metabolism, including tachycardia, palpitations, and diaphoresis

Question 35

Actions: Implement cooling measures with elevated temperature

Answer 35

temperature elevation and increased insensible fluid loss results secondary to accelerated metabolic rate
-instituting cooling measures decreases risks associated with hyperthermia

Question 36

Actions: Administer Eye Lubricant

Answer 36

to decrease possible eye dryness and potential for corneal irritation secondary to incomplete eyelid closure with exopthalmos

Question 37

Nursing Teaching

Answer 37

• overview of disease process
• take the anti-thyroid medication at the same time everyday
• consume adequate calories to minimize weight loss

Question 38

Teaching: Overview of the disease process

Answer 38

it is important that the patient and family are able to detect early signs of both hyperthyroidism (underlying disorder that could progress to thyroid storm)and hypothyroidism (secondary to thyroid-hormone blocking agents)

Question 39

Teaching: Take the anti-thyroid medications at the same time each day

Answer 39

compliance with the anti-thyroid medication is essential for minimizing complications associated with thyrotoxicosis

Question 40

Teaching: Consume adequate calories to minimize weight loss

Answer 40

weight gain or maintenance of current weight indicates the therapeutic effects of anti-thyroid medications

Question 41

Evaluating Care Outcomes

Answer 41

usually managed with anti-thyroid medications

• vital signs within normal limits and stable weight indicate stabilizing thyroid function
• should have an elevation of thyroid function before undergoing surgical or invasive procedures
• adjustments of anti-thyroid medications may also be indicated during times of stress, which can further accelerate the metabolic rate

Question 42

Medication: Propylthiouracil (PTU)

Answer 42

Action: inhibits the synthesis of thyroid hormone by diverting iodine pathways; interferes with conversion of thyroxine (T4) and triiodothyronine (T3)
>Implications:
-take the medication at the same time daily, usually in the morning
-monitor weight 2-3 times per week
-teach patients signs of hypothyroidism
-monitor white blood cell count because agranulocytosis may occur

Question 43

Medications: Methimazole (Tapazole)

Answer 43

Action: inhibits the synthesis of thyroid hormone by blocking the combination of iodine with a protein called thyroglobulin; methimazole also interferes with the conversion of T4 and T3
>Implications:
-take the medications at the same time daily, usually in the morning
-monitor weight 2-3 times per week
-teach patient signs of hypothyroidism
-monitor white blood cell count as agranulocytosis ,ay occur

Question 44

Medications: Lithium Carbonate (Lithonate)

Answer 44

Action: Lithium is concentrated in the thyroid gland and interferes with thyroid hormone synthesis and can cause formation of thyroid antibodies
>implications:
-monitor for signs of toxicity including vomiting, diarrhea, drowsiness, and lack of coordination
-drink at least 2-3 L of fluids when initially starting the medication
-assess for changes in signs of thyroid dysfunction

Question 45

Medications: Iodine (SSKI- saturated solutions of potassium iodine)

Answer 45

Action: inhibits release of thyroid hormone by decreasing vascularity of the thyroid glands
>implications:
-assess for signs of iodism including metallic taste, stomatitis, skin lesion, cold symptoms, and severe GI distress
-mix solutions in full glass of fruit juice or water
-administer after food to decrease GI distress